Come as You Are (7 page)

the dual control model

YOUR SEXUAL PERSONALITY

Laurie hadn’t actually
wanted
sex with her husband, Johnny—I mean, really
craved
it—since before their son Trev was born. At first she figured it was the pregnancy. Then she figured it was a postpartum thing.

Then she figured she was just tired.

Or depressed.

Or maybe she didn’t actually love her husband.

Or maybe she was broken.

Or maybe humans just aren’t meant to stay erotically connected after the months of cleaning baby puke off each other’s shirts.

They’d had a great run. Right up until she got pregnant, their sex life was the kind of thing you find in romance novels—hot, hungry, passionate, sweet, loving, and just kinky enough to give them something wicked to think about as they locked eyes over his parents’ Thanksgiving dinner table.

So maybe that was all they got. Maybe the rest of their lives would be sexless.

Still, they’d been trying. They’d bought some toys and massage oil. They’d tried tying her up, tying him up, using flavored lube, videoing themselves, playing games . . . and sometimes it worked, all this exploration.

But mostly it didn’t. Mostly Laurie wound up feeling sad and lonely because she loved Johnny, loved him so much it hurt, yet she couldn’t make herself want him, not even with all the novelty and adventure available to them in a twenty-first-century world of technology, fantasy, and permissiveness.

One side benefit of this whole situation was that Laurie found she could have an orgasm in about five minutes with the vibrator, and that made falling asleep easier. So she’d go to bed early and buzz herself to sleep. But she hid it from Johnny, because she was pretty sure he’d be unhappy to learn that she was having orgasm on her own but not with him. It puzzled her, this interest in solo orgasm, when hardly anything could prompt her to want sex with her husband.

So she felt stuck and confused and crazy when she sat down to talk with me about it.

Her perception of the situation—and her sense of hopelessness—changed completely when she learned what’s in this chapter: Your sexual brain has an “accelerator” that responds to sexual stimulation, but it also has “brakes,” which respond to all the very good reasons not to be turned on right now.

Imagine it’s 1964 and you’re working in the laboratory of groundbreaking sex researchers William Masters and Virginia Johnson, at Washington University in St. Louis. You’re on the cutting edge of science, working to understand what has never been studied before, and you spend a lot of time posting want ads in the local paper. You’re looking for people, ordinary people, who are not only willing but also able to have orgasm in a laboratory (“research quarters”) while connected to machines that measure their heart rate, blood pressure, blood flow, and genital response, with you and the team of scientists in the room, observing.

When a woman responds to the ad, you invite her to the lab, where you take a detailed medical and sexual history, you conduct a physical
exam to check for any health issues, and you introduce her to the research quarters and its equipment. Next time she comes in, she practices having an orgasm in the research quarters, first on her own and then with the research team there in the room with her.

Now she’ll be observed, measured, and assessed as she stimulates herself with the equipment in the research quarters, all the way to orgasm. For science.

This is what you’ll observe:

Excitement.
As stimulation begins, her heart rate, blood pressure, and respiration rate increase, and her labia minora and the clitoris darken and swell, separating the outer labia. The walls of the vagina begin to lubricate and then lengthen. Her breasts swell and the nipples become erect. Late in excitement, she may begin to sweat.

Plateau.
Lubrication begins at the mouth of the vagina, from the Bartholin’s glands. Her breasts continue to swell, so much that the nipples seem to retract into the breasts. She may experience “sex flush,” a concentration of color over the chest. By now her inner labia have doubled in size from their resting state. The internal structures of the clitoris lift, drawing the external portion up and inward, so that it retracts from the surface of the body. The vagina itself “tents” around the cervix, open and wide deep inside the body. She experiences the involuntary muscle contraction known as myotonia, including carpopedal spasms (contraction of muscles in the hands and feet). She may begin to pant or hold her breath, as the thoracic and pelvic diaphragms contract in unison.

Orgasm.
All the sphincters of her pelvic diaphragm (the “Kegel” muscle) contract in unison—urethra, vagina, and anus. She experiences rapid breathing, rapid heartbeat, and increased blood pressure. Her pelvis may rock, various muscle groups may tighten involuntarily. She experiences the sudden release of the tension that has accumulated in the muscles throughout her body.

Resolution.
Breasts return to baseline, clitoris and labia return to baseline, heart rate, respiration rate, blood pressure all return to baseline.

This four-phase model of sexual response quickly became the
foundation of sex therapists’, educators’, and researchers’ understanding of the human sexual response. As the first scientific description of the physiology of sexual response, it would become the basis for defining sexual health and also sexual problems.

Now imagine you’re a sex therapist in the 1970s, using the four-phase model to understand and treat clients with sexual dysfunction. Some of them you can help. Clients with anorgasmia (lack of orgasm) can learn to have orgasms, those with premature ejaculation can learn to control orgasm, those with vaginismus (vaginal spasms) can learn to relax those muscles. But there’s a group of clients who just don’t seem to respond to therapy informed by the four-phase model.

This is what happened to psychotherapist Helen Singer Kaplan. Reviewing treatment failures among her own and her colleagues’ patients, she found that the clients with the least successful outcomes were those who lacked interest in sex. Kaplan realized something important was entirely missing from the four-phase model:
desire
. The entire concept of sexual desire was utterly missing from the dominant theory of human sexual response.

It seems like a glaring oversight in retrospect, but of course it was missing—people who come to a laboratory to masturbate for science don’t have to
want
sex before they begin; they just have to get aroused for the purpose of the experiment.

So Kaplan took the four-phase model out of the laboratory and adapted it to the lived experience of her clients. Her “triphasic” model of the sexual response cycle begins with desire, which she conceptualized as “interest in” or “appetite for” sex, much like hunger or thirst. The second phase is arousal, which combines excitement and plateau into one phase, and the third phase is orgasm.

For decades, Kaplan’s new triphasic model of sexual response served as the foundation for diagnostic criteria in the American Psychiatric Association’s
Diagnostic and Statistical Manual
. You could have normal or problematic desire, normal or problematic arousal, and normal or problematic orgasm. A number of these diagnoses now have effective
treatments, including cognitive-behavioral therapy, mindfulness, sensorimotor therapies, and pharmaceuticals.

Fast-forward to 1998. Viagra: a pill that gives men erections.

Now imagine you’re a researcher for a pharmaceutical company. Erectile dysfunction drugs have hit it big and the pressure is on to find a “pink Viagra,” a drug that can do for women what Viagra does for men. You try giving Viagra to women—it doesn’t work. You test testosterone and estrogen—it works for only a small minority of women. You try antidepressants—nothing.

And today, nearly two decades later, pharmaceutical companies are still looking for this “pink Viagra.” If any drug worked for women, it would be a commercial bonanza—imagine being able to take a pill and just want sex, without effort, without hassle. It’s such a tantalizing idea that, despite lacking approval by the Food and Drug Administration (FDA), the pharmaceutical company Pfizer spent tons of money promoting off-label use of Viagra in women; the idea took off, with experts on
Oprah
and an entire story line (suspiciously similar to a product placement . . .) in
Sex and the City
, just for a start.
¹

But, as I said, these medications don’t work on women.

Just as Kaplan looked at sex therapy treatment failures and found a missing piece—desire—in the Masters and Johnson model, we can look at the failure of the pharmaceutical industry to find a medication for women’s sexual functioning and find a missing piece in the Kaplan model.

This chapter introduces that missing piece.

In the first section of the chapter, I’ll describe the basic theory of the “dual control model” of sexual response, which proposes a sexual “accelerator” and sexual “brakes.” The brake is the missing piece, the reason these drugs don’t work on women. And like desire, once someone points it out, it’s obvious . . . and it changes your entire understanding of how sex works.

In the second section of this chapter, I’ll talk about individual differences in the sensitivity of the brake and accelerator. This variation impacts how a person responds to the sexual world. We’ll find that while,
yes, as you’d expect, men often have more sensitive accelerators and women have more sensitive brakes, there’s far more variation within those groups than between them. What’s more interesting than just how sensitive the mechanisms are is how these mechanisms relate to your mood and to your environment.

And that’s what the third section is about: what the brakes and accelerator respond to. What on earth is a “sexually relevant stimulus”? What kind of “potential threat” causes our brains to hit the brakes? How does our brain know what to respond to and what not to respond to? And can we change that?

I bet that before you picked up this book, you already knew that female genitals include a vagina and a clitoris, and you already knew that arousal, desire, and orgasm are things people generally experience as part of sexual response. Once you’ve read this chapter, I want you to feel that your accelerator and your brakes are as basic, as integral to your sexual functioning, as your clitoris and your desire. If I do my job in the next few pages, you’ll be telling everyone you know: “OMG, everybody,
there’s a brake
!”

The Power of Context

Erectile dysfunction drugs don’t improve women’s sexual functioning, but they do have one of the strongest placebo effects observed in medical research. Around 40 percent of participants in the placebo group of a clinical trial of sexual dysfunction medication report that the “drug”—actually a sugar pill—improved their sex lives; this is a response size so large that one particularly brilliant study reported only the effects of an eight-week “treatment” with a placebo.
²
This is just one small hint at the power of context in shaping our sexual experience, which we’ll discuss in chapter 3.

turn on the ons, turn off the offs

Allow me to introduce you to the dual control model.

Developed in the late 1990s by Erick Janssen and John Bancroft at the Kinsey Institute, the dual control model of sexual response goes far beyond earlier models of human sexuality, by describing not just “what happens” during arousal—erection, lubrication, etc.—but also the central mechanism that governs sexual arousal, which controls how and when you respond to sexually relevant sights, sounds, sensations, and ideas.
³

The more I learned about the dual control model during my graduate education, the more I felt the lights come on in my understanding of human sexuality. I’ve been teaching it to my students for more than a decade now, and the more I teach it, the more I see how valuable it is in helping people to understand their own sexual functioning.

Here’s how it works:

Your central nervous system (your brain and spinal cord) is made up of a series of partnerships of accelerator and brakes—like the pairing of your sympathetic nervous system (“accelerator”) and your parasympathetic nervous system (“brake”). The core insight of the dual control model is that what’s true for other aspects of the nervous system must also be true for the brain system that coordinates sex: a sexual accelerator and sexual brake. (Daniel Kahneman wrote of his own Nobel Prize–winning research in economics, “You know you have made a theoretical advance when you can no longer reconstruct why you failed for so long to see the obvious.” So it was with Kahneman’s prospect theory, and so it is with the dual control model. I stand ready to send Erick and John large fruit baskets on the day the Nobel committee gets its act together and recognizes the importance of their insight.) So the dual control model of sexual response, as the name implies, consists of two parts:

Sexual Excitation System (SES).
This is the accelerator of your sexual response. It receives information about sexually relevant stimuli in the environment—things you see, hear, smell, touch, taste, or imagine—and
sends signals from the brain to the genitals to tell them, “Turn on!” SES is constantly scanning your context (including your own thoughts and feelings) for things that are sexually relevant. It is always at work, far below the level of consciousness. You aren’t aware that it’s there until you find yourself turned on and pursuing sexual pleasure.